PONE-D-24-06637Informed choice of modern Contraceptive Methods and determinant factors among reproductive age women in Eastern Africa countries: A Multilevel Analysis of Demographic and Health Survey.PLOS ONE

Dear Dr. zeleke,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 22 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Yitagesu Habtu Aweke, Ph.D

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please provide a complete Data Availability Statement in the submission form, ensuring you include all necessary access information or a reason for why you are unable to make your data freely accessible. If your research concerns only data provided within your submission, please write "All data are in the manuscript and/or supporting information files" as your Data Availability Statement.

3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager.

4. Please amend either the abstract on the online submission form (via Edit Submission) or the abstract in the manuscript so that they are identical.

5. Please include a separate caption for each figure in your manuscript.

6. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 5 in your text; if accepted, production will need this reference to link the reader to the Table.

Additional Editor Comments:

• You reported an “informed choice” prevalence of 20.70% from DHS data spanning 2012 to 2020 across eight East African countries. Meanwhile, a study covering nine East African countries (DHS 2015–2021, DOI: 10.1371/journal.pone.0297018) reported an overall modern contraceptive prevalence of 45.68%. How do you explain such a significant gap between informed choice and modern contraceptive use, given that family planning counselling is expected to ensure informed decision-making at initiation?
• Your study excluded Madagascar and Tanzania but included Comoros. What was the rationale behind selecting these countries? Was it related to data availability, methodological concerns, or another reason?
• You used DHS data from 2012 to 2020 despite the availability of more recent data (2015–2021).Why did you choose an earlier timeframe instead of leveraging the latest data?
• Could this choice affect the relevance of your findings? Please elaborate further on how your study adds new insights to the existing body of knowledge on family planning and informed choice. What gaps does it fill over the existing data?
• Could you explain more clearly how you defined and operationalised your outcome variables? This clarification will help in understanding the study's methodology and its implications.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear author

Conducting a study on contraceptive methods is required in all countries. Therefore, conducting this study is commendable. Below are comments to improve the article.

Abstract:

1. Please correct this sentence:

This study concluded that the proportion of reproductive age women using modern contraceptive techniques made an informed choice in eight nations in Eastern Africa.

Introduction

1. Do you have statistics on unwanted pregnancies in East Africa? If you have statistics, please write.

2. Do you have statistics on illegal abortions? If you have statistics, please write.

3. It seems that illegal abortions following uninformed choice of contraceptive methods are your concern and this is the necessity of your study. Please explain more about this issue. Explain that illegal abortions threaten women's reproductive health.

Methods

1. Barrier methods and vasectomy methods are not among the methods?

Discussion

1. Why is there no discussion of non-significant variables?

Reviewer #2: � Comments to Authors:

Abstract:

• please correct the linguistic error of repetition in the following phrase “Data from Data from the recent DHS” stated in the subtitle “method”.

Title:

• The title of the study is clear, inclusive and precise to the study’s objectives and aims. The authors stated the study design distinctly. However, concerns are regarding using “modern” description for a well-known methods of contraception.

Introduction:

• The rationale and aim of the study are well stated.

• The introduction would benefit from a more comprehensive description of how family planning services are being delivered in the research area; this would help make the context clearer for readers and researchers unfamiliar with Sub-Saharan Africa.

• While the idea of informed choice when choosing contraception method has been stated several times as an important factor, further elaboration is needed on its broader effects, beyond just preventing unwanted pregnancies. Specifically, a more direct link between informed choice and lower contraceptive discontinuation rates would strengthen the argument.

• The inclusion of statistical data from countries like India, Bangladesh, Kenya, Ethiopia, and sub-Saharan Africa adds strength to the argument. However, there is a lack of explanation about these statistics. How were these numbers gathered? Clarifying how informed choice was ensured and its relationship to better contraceptive choices would add credibility and impact to the discussion.

Methods:

• The methods section provides a comprehensive description of the study design, data source, population, and statistical analysis. Moreover, Tables summarizing key variables are quiet helpful.

• The authors clearly explain the weighted sample size, which helps strengthen the reliability of the method.

• The explanation of the statistical models (e.g., multilevel mixed-effects logistic regression) is detailed but might be difficult to follow for readers unfamiliar with advanced statistical methods.

• Also, the use of specialized terms such as "proportional change in variance" (PCV), "intra-class correlation coefficient" (ICC), and "variance inflation factors" (VIF) may be challenging for some readers. It would be beneficial to define these terms more clearly, when they first appear or provide references for readers unfamiliar with them.

• Regarding “outcome” variables, the authors conducted a questionnaire survey that would define and assess “informed choice” such as; knowing the side effects and other available methods. Nevertheless, many other aspects are worth mentioning in order to label it as “informed choice”. These aspects includes but not limited to:

� Access to information: providing clear details about each method, each method , its effectiveness, side effects, and any medical or personal considerations.

� Understanding Options: Ensuring that individuals understand the information provided and can ask questions to clarify any uncertainties.

� Freedom of choice: must have the autonomy to choose the method that best suits their personal needs and preferences without any pressure from healthcare provider or a family member.

• While the methodology is well-detailed, the section could benefit from a brief mention of potential limitations in the way informed choice is measured.

• Overall, the methods section is well-organized and provides a thorough description of the study's design and analysis. With a few clarifications and improvements, it would be more accessible to a wider audience.

Results:

• The authors conducted a thorough analysis of the results, supported by sufficient amount of data justifying the conclusion.

• The data are clearly presented by the authors, and the use of percentages for each variable enhances the clarity of the findings. The study's main result, showing the magnitude of informed choice among women using modern contraceptives, is well articulated (20.70%).

Discussion:

• The author effectively highlights key findings and discusses the demographic and socio-economic factors that contribute to this low rate.

• The comparison with other studies in sub-Saharan Africa, such as those in Ethiopia, India, and broader African contexts, is useful in contextualizing the results and offering possible explanations for the discrepancies observed.

• While the authors mentioned multiple contributing socio-economic factors, it would be beneficial to delve deeper into how specific health policies or community-level interventions could address the lack of informed choice, particularly in rural areas. This could provide actionable insights for policymakers.

• Overall, the discussion section is informative and offers a solid interpretation of the study results.

Strength and Limitation:

• The acknowledgment of limitations such as the potential for recall bias demonstrates transparency and a clear understanding of the study's constraints. This might provide a guidance for future researches.

Conclusion:

• Correctly answered the research question.

• The authors effectively highlights the factors associated with informed choice, such as maternal age, education, media exposure, and health facility visits.

• Including recommendations and suggestions for improving informed choice aimed at healthcare policymakers and media representatives would enhance the conclusion.

Minor:

• Some minor grammatical issues could be addressed to improve readability.

• English editing and proofreading by a native English speaker needed. The authors should correct some typos and language mistakes.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-24-06637.pdf

Attachment

Submitted filename: Peer_Review contraception.docx

PONE-D-24-06637R1Informed choice of modern Contraceptive Methods and determinant factors among reproductive age women in Eastern Africa countries: A Multilevel Analysis of Demographic and Health Survey.PLOS ONE

Dear Dr. zeleke,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 26 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Yitagesu Habtu Aweke, Ph.D

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: Yes:  Bayan Al Omari

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Informed choice of modern Contraceptive Methods and determinant factors among reproductive age women in Eastern Africa countries: A Multilevel Analysis of Demographic and Health Survey.

PONE-D-24-06637R2

Dear Dr. Gebreeyesus Abera,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Yitagesu Habtu Aweke, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

• Please make your recommendation under the subsection of "Conclusion".

Reviewers' comments: